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6. Screening and Case Identification in Clinical Settings
Pages 104-120

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From page 104...
... Pertinent health service settings include all levels of primary, secondary, and tertiary care, including long-term care institutions. While it is important to understand the determinants and occurrence rates of elder mistreatment through population-based studies, it is also critical to identify victims in diverse settings where they frequently appear and where many of the consequences of mistreatment are likely to be manifest.
From page 105...
... ~ Assessment · Safety · Health end functional status · Frequency, severity, and intent · Access · Social andfinancial resources · Cognitive status · Emotional status Reason to believe that mistreatment has occurred; plan intervention No mistreatment found FIGURE 6-1 Diagnostic and treatment guidelines on elder abuse and neglect, Part I SOURCE: American Medical Association (1992:13~.
From page 106...
... Validation of each step is an important aim of research. A LEAD standard would be the appropriate means of validating any proposed screening method prior to its widespread application.
From page 107...
... A critical feature of the screening process is the cutoff point for deciding whether the case is screened in or out; this task often involves considerable discretion, highlighting the continuing tension between statistical and clinical methods of screening. When the screening activity indicates a positive result, a case identification investigation is initiated in order to definitively confirm or refute the positive suspicion.
From page 108...
... These methods are more readily applied to conditions that can definitely be designated as being present or absent. For example, a clinical outcome such as a cancer, high blood pressure, or high blood cholesterol can be reliably determined in most circumstances, and the properties of screening tests are well understood.
From page 109...
... encourage physicians to "incorporate routine questions related to elder abuse and neglect into daily practice." Table 6-1 contains a listing of published screening methods for elder mistreatment, along with information on their measurement properties. While several screening tools are now available to identify possible cases of elder mistreatment, it is not known if these tools are widely utilized; anecdotal evidence indicates they are not.
From page 110...
... To enable practitioners to identify abuse cases among health and social services agency clients. 15 items Elder as respondent.
From page 111...
... 341 health and alpha = 0.91 The performance of social services the IOA was agency cases (55 evaluated against and older)
From page 112...
... those published, such as the Hwalek-Sengstock Elder Abuse Screening Test and the Elder Assessment Instrument, require referral to a more specialized assessment process. Often, no well-established or specialized assessment process is available in many clinical settings; putative cases are reported to the community adult protective systems, which may vary in assessment rigor and standardization, adding to the challenge of screening instrument evaluation.
From page 113...
... . carryovers receiving care from a social services center.
From page 114...
... Others may spend time in a variety of settings, such as senior centers or adult day care centers. The varied distribution of social environments may alter risk profiles and the performance of screening instruments.
From page 115...
... While the complaints and investigative processes are tracked by every state, the methods of case validation preceding the finding varies widely from state to state. The starting point for adult protective services response to a complaint of alleged elder mistreatment is the state statute and administrative rules.
From page 116...
... While adult protective services units have developed several instruments and guidelines to carry out their state mandate for example, screening, investigation and evaluation of mental competence and have shared best practices among the states, they are well aware of the need for validation and research and of the subjective nature of the decision making often required in conducting assessments-investigations. The processes of case identification and case management are in need of research for all of its components.
From page 117...
... Research assessing the capacity of older persons with cognitive impairments to provide accurate testimony is needed for improving the accuracy of case identification, not only in clinical settings, but also in legal settings, including prosecutorial decision making and formal adjudication. Another impediment to accurate case identification is that many elders have conditions that are associated with physical frailty and other medical problems as well as psychological or emotional problems.
From page 118...
... Applying Causal Logic to Case Finding In addition to the determination of relevant conduct and harm, the occurrence of mistreatment requires a determination of cause, especially in studies aiming to improve clinical methods of case identification and screening. In some cases the co-occurrence of harm and relevant conduct is such that an unequivocal determination that the perpetrator's conduct caused the harm can be made.
From page 119...
... There are to our knowledge no published studies of physical markers of elder mistreatment that help distinguish preventable, unavoidable signs from those that are intentional, inflicted, or avoidable. One study of skin tears in nursing home residents described the characteristics of the tears, but almost half (48 percent)
From page 120...
... Candidate techniques include improved questionnaire designs; record linkage to other clinical, public health, social and legal databases; automated alerts based on concurrent clinical records; and previously defined risk status based on prescreening methods. Special attention should be placed on the predictive value of various clinical injuries and other relevant clinical findings as indicators of mistreatment for therapeutic, social, and forensic reasons.


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